PR to Resmed Transition - Need Help

I have been on APAP for over 17 years, and joined this forum around the same time back in 2005. From the beginning I have been on PR machines, initially the Remstar Auto and then the System One 60. I have almost 50,000 hours of use between these two.

Mostly, I felt like I had gotten decent therapy with PR. After settling in my AHI numbers were almost always under 1. Ever since PR dropped the foam issue on us and disrupted many of our lives, like others, I have working to find a solution for myself. In 2021, when I received the recall letter from PR, I immediately took my primary System One machine apart and removed the foam. Now, unfortunately, PR has notified me that my System One machines (I have two) are too old, according to PR, to be replaced. I’m still working through that.

At this point I decided to walk away from PR and make the transition to Resmed, so I bought a new Airsense 11 Autoset from cpap.com. The AS11 arrived on 10/06 and I started my first night of therapy on 10/08.

Unfortunately, the transition is, so far, not going all that great. I am struggling to find the right pressure range, and dealing with some insomnia and congestion issues simultaneously. After a lot of research on this site and others, I have kind of reached an impasse on how to proceed.

I find Resmed to be much more aggressive with pressure than PR. I have tried several different pressure combinations (11-15, 12-17, 12.6-17.6, 12-20), and it seems whatever I give the AS11 it will use it all. I woke up one night trying to breath out against almost 20cm of pressure. I frequently have clusters of Hypopneas and Flow limitations 3 to 5 times each night and whether my max is 15 or 20 they still seem to occur. My AHI has varied from a low of 0.86 to a high of 3.45 with most being over 1.0, but I only have 8 nights with the AS11 so far. Having said that, for the last two to three weeks I have been experiencing bad congestion (probably ragweed here in Atlanta). That is certainly having some affect my therapy.

Since I have been using Sleepyhead and now Oscar for many years I decided to go back and take a deep look at some System One data from several months ago. I haven’t looked deep into the data in years, since my AHI was almost always less that one, and I have felt pretty good. When I looked at the data, I am seeing some of the same issues in that data too, the only difference is the System One fails to detect and react to a lot of it, whereas the AS11 detects and reacts to much more of it. This makes me think that, although I have been feeling ok the last few years, maybe I can feel even better.

On the up side, a few of the nights that I have spent with the AS11 have resulted in feeling really good, better than usual the next day, despite the aggressive pressure disruptions. One of those nights was an AHI or 0.86 while the other was 2.92, so that really doesn’t tell me much. I’m not sure if this is a placebo effect or a real effect, but it makes me want to continue to search for a solution.

At this point I would definitely appreciate any suggestions that others may have. I’m not sure what to try next. I have lots of data that I can show if that will help.

Thanks, BP

Set the response to soft, this will result in gentler pressure increases.

If you are having trouble tolerating the high pressures, consider setting a max pressure, at or about what you can tolerate.

Do you have EPR turned on?

Post some graphs with some typical nights so we can see some of the actual behaviors of your therapy.

BP wrote: ↑

Wed Oct 19, 2022 12:39 pm

have tried several different pressure combinations (11-15, 12-17, 12.6-17.6, 12-20)

What were your pressure settings on your PR machines?

BP wrote: ↑

Wed Oct 19, 2022 12:39 pm

I have been on APAP for over 17 years, and joined this forum around the same time back in 2005. From the beginning I have been on PR machines, initially the Remstar Auto and then the System One 60. I have almost 50,000 hours of use between these two.

What pressure range did you use on your PR System One 60 Auto? Were you using A-Flex, and if so, what setting were you using? Also, what humidifier setting were you using and did you use a heated hose? If so, what was it set to?

At this point I decided to walk away from PR and make the transition to Resmed, so I bought a new Airsense 11 Autoset from cpap.com. The AS11 arrived on 10/06 and I started my first night of therapy on 10/08.

Unfortunately, the transition is, so far, not going all that great. I am struggling to find the right pressure range, and dealing with some insomnia and congestion issues simultaneously. After a lot of research on this site and others, I have kind of reached an impasse on how to proceed.

Did the insomnia and/or congestion start with the change of machines?

Or were you already having one or both problems when you were still using the System One? And has the switch to the Resmed made either problem worse? If so, in what way?

As for the insomnia, is the problem getting to sleep or staying asleep? What, if anything, are you trying to do to try to control the insomnia?

I find Resmed to be much more aggressive with pressure than PR. I have tried several different pressure combinations (11-15, 12-17, 12.6-17.6, 12-20), and it seems whatever I give the AS11 it will use it all. I woke up one night trying to breath out against almost 20cm of pressure.

Resmed's Standard Auto algorithm is much more aggressive than PR's is. That is part of why I am reluctant to throw the towel in on my PR Dreamstation BiPAP Auto and just replace it with a Resmed Aircurve 10 VAuto. Are the pressure increases waking you up?

Also, what was the 90% pressure level on your System One over the last couple of months you used it? Is the Resmed regularly exceeding that 90% pressure level on the System One by a lot?

You should try switching to the "Soft" Auto algorithm: It is supposed to be more gentle. But whether that means it increases the pressure more slowly or doesn't increase the pressure as far or both is not something I've seen anybody describe on the forum.

I frequently have clusters of Hypopneas and Flow limitations 3 to 5 times each night and whether my max is 15 or 20 they still seem to occur. My AHI has varied from a low of 0.86 to a high of 3.45 with most being over 1.0, but I only have 8 nights with the AS11 so far. Having said that, for the last two to three weeks I have been experiencing bad congestion (probably ragweed here in Atlanta). That is certainly having some affect my therapy.

Post some data from Oscar please. And when you say you have clusters of events 3-5 times a night, but your AHI is between 0.86 an 3.45, that must mean that on most nights there can't be very many events in each cluster.

Any chance these clusters are somehow related to your insomnia? If so, do you wake up first and then have a bunch of SWJ events scored while trying to get back to sleep? Or are you having real obstructive events that eventually lead you to waking up?

Since I have been using Sleepyhead and now Oscar for many years I decided to go back and take a deep look at some System One data from several months ago. I haven’t looked deep into the data in years, since my AHI was almost always less that one, and I have felt pretty good. When I looked at the data, I am seeing some of the same issues in that data too, the only difference is the System One fails to detect and react to a lot of it, whereas the AS11 detects and reacts to much more of it.

Exactly what is the AS11 detecting more of? Actual events like OAs and Hs? Or is it flow limitations that are triggering the pressure increases? The Resmed Auto algorithm is extremely aggressive in scoring and reacting to flow limitations, but some people's flow limited breathing patterns do not magically smooth out just by throwing more and more pressure at them. Sometimes all the extra pressure does is cause additional arousals and more unstable breathing that gets misinterpreted as flow limited breathing.

The question is whether the AS11 is reacting to something real or not. Not everybody's flow limited breathing patterns magically smooth out just by throwing more and more pressure pressure at the airway. But that's exactly what the Resmed auto algorithm seems to do. The PR machine would increase pressure and then wait to see if the flow limitations got better or worse or stayed about the same before making a decision about whether to increase the pressure any further.

This makes me think that, although I have been feeling ok the last few years, maybe I can feel even better.

Maybe, maybe not.

It really depends on whether your AS11 is reacting to something real that can be fixed by throwing more pressure at your airway or not.

On the up side, a few of the nights that I have spent with the AS11 have resulted in feeling really good, better than usual the next day, despite the aggressive pressure disruptions. One of those nights was an AHI or 0.86 while the other was 2.92, so that really doesn’t tell me much. I’m not sure if this is a placebo effect or a real effect, but it makes me want to continue to search for a solution.

The real question is how often are those aggressive pressure increases disturbing your sleep?

At this point I would definitely appreciate any suggestions that others may have. I’m not sure what to try next. I have lots of data that I can show if that will help.

Showing some data would definitely help.

But it would also help to know what problem(s) you're trying to solve.

First, thanks so much to everyone who jumped on board, I very much appreciate it.

Ok, let me try to answer all the questions before posting any images.

1. I have been at 11-15 on my System One for about 4 years, and 10-15 for the 13 years before that.

2. I tried A-Flex initially but didn't like the in and out feeling, plus never had an issue exhaling against pressures up to 15.

3. So, because of that I haven't tried EPR assuming it was the same kind of thing. Although never had pressures of 20 to deal with.

4. Also, I have never used a humidifier. The last time I tried I didn't like the warm air, felt suffocating to me (this was during my first year on APAP, 14 years ago, however). I actually enjoy the cool apap air.

5. And, along that line, while I do take antihistamines regularly, the congestion did not start with the AS11. I am trying a new spray called Astepro, which seems to be helping a lot. Sometime I do mouth breath as well.

6. The insomnia, but not the congestion, started with the AS11. It hasn't been every night, but it most likely due to my worry especially after I looked at how rapidly the AS11 increases pressure, and waking me up with the pressure a few times. My main issue is falling asleep rather than staying asleep. Sometimes I take some Ambien or Melatonin to help.

7. I did try Soft a couple of nights, I really didn't notice much difference. It still hit the same pressures, keeping in mind that I have been adjusting the ranges quite a bit, and I have only had 8 nights using the AS11.

8. My 95% pressure level is consistently around 12.5 on my System One, it is higher with my AS11. I don't have a lot of nights of data yet to determine a pattern, but I see 13.5, 16.5, 14.96, 16.66, and then a couple in the 12s.

Ok, images to come next...

My Resp Rate is all messed up due to Cardioballistic issues I believe. Here is a zoomed in image from last night. Clearly my Resp Rate is not in the high 30's to 40's like it says. By my count it is maybe 17 or 18. I am also concerned that the algorithm may be seeing these Cardioballistic effects as flow limitations, although someone noted in a post that it filters them out. I hope so?
Here is a night where I felt really good the next day. Pressure didn't weren't too bad.
Here is last night which didn't go too well.

Here is a zoomed in image of last night in one of the clusters. Pressure close to 18. Lots of flow limitations.

Do you ever end up sleeping on your back? I am wondering if the clusters of events you see on the not so great nights are related to
sleeping position or REM stage sleep or maybe a little of both.

Pugsy, I don't think so. I am a side/stomach sleeper, and almost always wake up in the position I fall asleep, then turn to the other side. It could happen, but I have never woken up on my back, ever.

Well some parts of the night you don't need all that much pressure and other parts of the night it's obvious that the pressure isn't doing a good job because of the clusters....assuming you were asleep during those clusters.

The reasons we might need more pressure
1....sleeping position....it's common for OSA to worsen and/or need more pressure when on our backs
2....REM stage sleep...it's common for OSA to worsen and/or need more pressure when in REM stage sleep.

Those are the 2 most common reasons. There is another maybe reason and that is chin tuck position which makes it harder for the pressure to keep the airway stented open. A soft cervical collar might help if that is what is happening here but I have my doubts.

So one night nothing much happened with the pressures and no clusters of events. We would assume that you got some REM that night yet no clusters......really makes me think sleeping position is a likely culprit. If it was REM we would expect to see some sort of clustering even on the good night.

You have to look at what changed between the 2 nights to cause such a difference in pressure needs and results....and position or sleep stage is about all there is to look at. As to exactly what changed....dunno right now but something changed.

Uh oh, seems the attachment quota has been reached. I am going to try something using Google Drive.

If this works, this is a typical System One night from early September.

Can someone please let me know if this link works for you? Thanks.

https://drive.google.com/file/d/1a2Iio3 ... sp=sharing

Pugsy, I do kind of tuck my chin, but I always do that so not sure if it can explain the clusters. I did have 3 smaller clusters even on the good night, see image from link below. It also looks like some Hypopneas may be getting missed, but they may not pass the exact definition for the algorithm.

I agree I don't see the ramp in pressure affecting the clusters that much, just arousing me I think. I have had a few stretches of not being asleep. Actually last night I couldn't fall asleep, finally got up to use the rest room and noticed the pressure was 15.6 while awake. But, I could have dosed off not sure.

Thanks for taking a look. It is definitely a work in progress.

https://drive.google.com/file/d/1LuM04E ... sp=sharing

Pugsy wrote: ↑

Wed Oct 19, 2022 5:38 pm

Well some parts of the night you don't need all that much pressure and other parts of the night it's obvious that the pressure isn't doing a good job because of the clusters....assuming you were asleep during those clusters.

The reasons we might need more pressure
1....sleeping position....it's common for OSA to worsen and/or need more pressure when on our backs
2....REM stage sleep...it's common for OSA to worsen and/or need more pressure when in REM stage sleep.

And hitting REM while sleeping on your back may require more pressure than either back sleeping, but not in REM or REM sleep, but not on your back.

So one night nothing much happened with the pressures and no clusters of events. We would assume that you got some REM that night yet no clusters......really makes me think sleeping position is a likely culprit. If it was REM we would expect to see some sort of clustering even on the good night.

It could also be that REM sleep is particularly problematic when combined with back sleeping.

Are you having very much nasal congestion? Nasal congestion will sometimes show up as increased flow limitations and cause the machine to increase the pressure trying to kill off the FLs but if the FL graph activity is from nasal congestion more pressure isn't going to fix it.
The machine can't tell the difference between nasal congestion FLs and airway collapsing FLs so it just tries to kill all of them.

Definitely did get some clusters even on the good night. Since I couldn't post anymore images I added a link to the image in google drive. Hopefully they can be used by everyone. Put the link in a previous post above.

I never sleep on my back, so I think back sleeping is not applicable.

BTW, the problem I'm trying to solve is sleeping through the night and feeling good the next day, mostly like I have been doing for many years.